ICBDSR Report 2024

Chile RENACH, 2017 to 2017

  • total births in the 1-year period: 137,324 (livebirths: 136,453)
  • average births per year: 137,320 (livebirths: 136,450)
  • terminations of pregnancy legal in country: Yes
  • data include terminations of pregnancy: Yes
  • source structure: Hospital based

Country where the program is located

A word from the program

The RENACH program is hospital-based and covers approximately 60 % of livebirths delivered at public and private maternity hospitals in Chile. The program also includes data on stillbirths and voluntary pregnancy terminations from the stillbirth and pregnancy termination databases. All three registries collect information from both public and private maternity facilities in the country. Reporting of stillbirths and voluntary pregnancy terminations is mandatory nationwide.


Selected data highlights

The following tables highlight selected sets of congenital anomalies, each with a specific focus.

Top Ten

Here are the program’s top ten conditions by frequency, selected among those with significant clinical and public health impact. These are the conditions that one is more likely to encounter in the population under surveillance and impact the largest number of individuals and their families.

Top 10 Conditions by Frequency

among specific diagnoses with major health impact, Chile RENACH, 2017-2017
shown are total cases for the reporting period, yearly average cases, and prevalence per 10,000

Condition Cases Yearly Avg Prevalence
Down syndrome 195 195 14.2
Cleft lip with or without cleft palate 121 121 8.8
Neural tube defects, total 117 117 8.5
Trisomy 18 60 60 4.4
Anencephaly 57 57 4.2
Cleft palate without cleft lip 53 53 3.9
Gastroschisis 53 53 3.9
Limb anomalies, total 48 48 3.5
Hydrocephaly 43 43 3.1
Spina bifida 38 38 2.8

Not included: microcephaly, undescended testis, and unspecified conditions. Microcephaly is included in the condition-specific tables.

Notable Seven

These conditions exemplify the impact of congenital anomalies on morbidity and mortality. For example, neural tube defects and critical congenital heart disease, when combined, account for approximately half of all infant deaths associated with congenital anomalies.

For several of these conditions, modifiable risk factors are well established, and primary prevention, if implemented appropriately, works. This implication is unpacked in a later section (‘what if scenario’).

Seven highly impactful conditions

selected on the basis of high morbidity and mortality, and potential for primary prevention
Chile RENACH, 2017-2017

Yearly cases

Percent
liveborn

Prevalence
per 10,000

Program

Country

Orofacial
Cleft lip with or without cleft palate 121 203 100 8.8
Cleft palate without cleft lip 53 90 100 3.9
Neural tube defects (NTD)
Neural tube defects, total 117 196 85 8.5
Anencephaly 57 97 74 4.2
Spina bifida 38 65 97 2.8
Heart
Tetralogy of Fallot 17 28 100 1.2
Transposition of great vessels 10 16 100 0.7
Hypoplastic left heart syndrome 9 16 100 0.7
Estimated from program prevalence extrapolated to total country births. Chile births for 2022 from World Bank

The full table

This more expansive set of major congenital anomalies, internal and external, includes most conditions of significant clinical and public health impact. A more detailed view of Trisomy 21 (Down syndrome) is included in a later section. Note: a child with multiple anomalies will be counted in all pertinent rows.

Selected congenital conditions by system

number of cases and prevalence (prev) per 10,000, for all births and livebirths
Chile RENACH, 2017-2017

All births Livebirths
Cases Prev 95% CI Cases Prev 95% CI
Neural tube defects (NTD)
Neural tube defects, total 117 8.5 7.0 - 10.2 99 7.3 5.8 - 8.7
Anencephaly 57 4.2 3.1 - 5.4 42 3.1 2.1 - 4.0
Spina bifida 38 2.8 2.0 - 3.8 37 2.7 1.8 - 3.6
Encephalocele 22 1.6 1.0 - 2.4 20 1.5 0.8 - 2.1
Other brain
Microcephaly 75 5.5 4.3 - 6.8 75 5.5 4.3 - 6.7
Hydrocephaly 43 3.1 2.3 - 4.2 42 3.1 2.1 - 4.0
Holoprosencephaly 9 0.7 0.3 - 1.2 8 0.6 0.2 - 1.0
Eye and Ear
Microtia 23 1.7 1.1 - 2.5 23 1.7 1.0 - 2.4
Anotia 12 0.9 0.5 - 1.5 12 0.9 0.4 - 1.4
Microphthalmos 5 0.4 0.1 - 0.8 5 0.4 0.0 - 0.7
Anophthalmos 4 0.3 0.1 - 0.7 4 0.3 0.1 - 0.8
Orofacial
Cleft lip with or without cleft palate 121 8.8 7.3 - 10.5 121 8.9 7.3 - 10.4
Cleft palate without cleft lip 53 3.9 2.9 - 5.0 53 3.9 2.8 - 4.9
Choanal atresia bilateral 0 0.0 0.0 - 0.3 0 0.0 0.0 - 0.3
Heart
Tetralogy of Fallot 17 1.2 0.7 - 2.0 17 1.2 0.7 - 1.8
Coarctation of aorta 11 0.8 0.4 - 1.4 11 0.8 0.3 - 1.3
Transposition of great vessels 10 0.7 0.3 - 1.3 10 0.7 0.3 - 1.2
Hypoplastic left heart syndrome 9 0.7 0.3 - 1.2 9 0.7 0.2 - 1.1
Gastrointestinal
Anorectal atresia/stenosis 30 2.2 1.5 - 3.1 30 2.2 1.4 - 3.0
Esophageal atresia 10 0.7 0.3 - 1.3 10 0.7 0.3 - 1.2
Small intestinal atresia/stenosis 0 0.0 0.0 - 0.3 0 0.0 0.0 - 0.3
Genitourinary
Hypospadias 24 1.7 1.1 - 2.6 24 1.8 1.1 - 2.5
Indeterminate sex 17 1.2 0.7 - 2.0 17 1.2 0.7 - 1.8
Cystic kidney 10 0.7 0.3 - 1.3 10 0.7 0.3 - 1.2
Renal agenesis 9 0.7 0.3 - 1.2 8 0.6 0.2 - 1.0
Undescended testis 5 0.4 0.1 - 0.8 5 0.4 0.0 - 0.7
Epispadias 1 0.1 0.0 - 0.4 1 0.1 0.0 - 0.4
Bladder exstrophy 1 0.1 0.0 - 0.4 1 0.1 0.0 - 0.4
Limb
Limb anomalies, total 48 3.5 2.6 - 4.6 48 3.5 2.5 - 4.5
Limb deficiency, transverse 17 1.2 0.7 - 2.0 17 1.2 0.7 - 1.8
Limb deficiency, axial 10 0.7 0.3 - 1.3 10 0.7 0.3 - 1.2
Polydactyly preaxial 8 0.6 0.3 - 1.1 8 0.6 0.2 - 1.0
Limb deficiency, unspec. 6 0.4 0.2 - 1.0 6 0.4 0.1 - 0.8
Limb deficiency, preaxial 5 0.4 0.1 - 0.8 5 0.4 0.0 - 0.7
Limb deficiency, postaxial 5 0.4 0.1 - 0.8 5 0.4 0.0 - 0.7
Limb deficiency, intercalary 4 0.3 0.1 - 0.7 4 0.3 0.1 - 0.8
Limb deficiency, mixed 1 0.1 0.0 - 0.4 1 0.1 0.0 - 0.4
Abdominal
Gastroschisis 53 3.9 2.9 - 5.0 52 3.8 2.8 - 4.8
Omphalocele 24 1.7 1.1 - 2.6 24 1.8 1.1 - 2.5
Diaphragmatic hernia 21 1.5 0.9 - 2.3 21 1.5 0.9 - 2.2
Prune belly sequence 3 0.2 0.0 - 0.6 3 0.2 0.0 - 0.6
Chromosomal
Down syndrome 195 14.2 12.3 - 16.3 183 13.4 11.5 - 15.4
Trisomy 18 60 4.4 3.3 - 5.6 24 1.8 1.1 - 2.5
Trisomy 13 21 1.5 0.9 - 2.3 14 1.0 0.5 - 1.6
Note a dash (-) indicates data not available or not provided

Program Comment

The program leads provide their insights on data, operations, and recent achievements. Their interpretation of the data is particularly valuable because of their local experience and knowledge.

Comments provided by Cecelia Mellado, RENACH program lead. The Registry started in 2016. In 2017 it covered 60 % of the total livebirths (219,494) delivered at public and private maternity hospitals in the country.

Data on stillbirths of 20 or more weeks of gestation are obtained from the national fetal mortality database.

The registry is based on the notification of cases identified from birth until discharge from the maternity and neonatology services. The record is made in an online platform by midwives, obstetricians, nurses, neonatologists, and pediatricians. In 2017 those that were responsible for the registry in each maternity were still in training.


Down syndrome (trisomy 21)

By far the most common chromosomal anomaly, Down syndrome is known to occur more frequently (has a higher risk of occurrence) in births of women with higher maternal age

This pattern is universally observed, provided there is no significant bias toward missing pregnancies with Down syndrome in older women (e.g., because of unreported pregnancy terminations)

Down syndrome, overall and by maternal age

separately for all births and livebirths, prevalence per 10,000 (Poisson exact confidence intervals)
Chile RENACH, 2017-2017

All cases Livebirths

Cases

Prev 95% CI

Cases

Prev 95% CI
All maternal ages 195 14.2 12.3 - 16.3 183 13.4 11.5 - 15.4
< 20 years 6 4.8 1.8 - 10.5 5 4.0 0.5 - 7.5
20 to 24 20 6.7 4.1 - 10.3 18 6.0 3.2 - 8.8
25 to 29 16 4.3 2.5 - 7.0 16 4.3 2.2 - 6.5
30 to 34 32 10.0 6.9 - 14.1 30 9.4 6.0 - 12.7
35 to 39 61 30.5 23.3 - 39.2 56 28.0 20.7 - 35.3
40 to 44 53 93.7 70.2 - 122.6 51 90.2 65.6 - 114.8
45+ years 4 111.4 30.4 - 282.8 4 111.4 30.4 - 282.8
Age unspec. 3 - - 3 - -
Age unspec. = maternal age unknown or unspecified

Down syndrome - maternal age pyramid

Because of the relation between prevalence of Down syndrome and maternal age, the maternal age distribution in the population is a major determinant of the number of conceptions with Down syndrome in the population.

For programs that have maternal age specific data, one can compare the maternal-age ‘pyramid’ for all births in the population with that of births with Down syndrome. Typically, the distribution is skewed, with a relative excess of births with Down syndrome among the more advanced maternal age groups.

Down syndrome - birth rates matter

Despite the considerably higher risk (rates) of Down syndrome in mothers over 40 or 45 years, these age groups contribute comparatively fewer affected births than younger age groups. This is because birth rates matter: fewer births in the more advanced age groups mean fewer cases overall from those age groups.

A Pareto chart helps highlight the cumulative contribution of different age groups to the total number of cases. This information can help inform strategies for testing and counseling.

Linking risk factor profile and congenital anomalies

The term triple surveillance refers to a model of public health surveillance that births includes the full causal chain, from a) risk factors, which influence the number of affected pregnancies; to b) the affected pregnancies themselves, that are vulnerable to adverse health outcomes; and to c) the health outcomes in affected individuals. The burden of risk becomes expressed eventually in the burden of disease.

Historically, birth defect surveillance has focused on the second element, the occurrence of congenital anomalies.

However, improving outcomes (morbidity, mortality, disability) requires understanding and tracking risk factors (to improve primary prevention) and health outcomes (to improve care). Triple surveillance advocates integrating the tracking of all three elements in this causal chain. Together, these three domains provide clinicians, public health professionals, and policy makers with information to act.

To highlight such context, the next sections provide elements of country demographics, outcomes (mainly early mortality), and selected risk factors. These data, particularly those on risk factors and outcomes, are sometimes directly measured, and sometimes estimated. Birth defect programs with their partners can supplement these data with local assessments.

Country demographics

A surveillance program operates within its country’s demographic situation and trends. This information adds meaning and context to birth defect surveillance information.

Demographic Indicators, Chile

on population, births, life expectancy
Key Indicator 2022 data
Total population 19,603,733
Number of births 230,442
Birth rate (per 1000 pop) 11.8
Fertility (births per woman) 1.5
Life expectancy at birth (years) 79.5
Source: World Bank (accessed Sept 2024)

From program to country

Many (though not all) programs cover a proportion of the country in which they operate. In this setting, a common question is what the program can tell use about the impact of congenital anomalies country-wide, under the assumption that the program information is a good estimator for the country itself. This assumption, of course, needs to be carefully examined, and the program staff typically has the local knowledge to help frame such estimates within the strengths and limitations of the data.

The table below uses the prevalence measured within the program to estimate the number of births with selected congenital anomalies for the entire country. These extrapolations have limitations, and in most cases are illustrative. However, at times a program that covers a proportion of the population may be the only practical window into congenital anomalies country-wide.

A window into the country: Chile, 2022 estimates

Country-wide estimates for selected conditions (230,442 births), extrapolating from program data

All cases liveborn % liveborn
Neural tube defects (NTD)
Neural tube defects, total 196 167
Anencephaly 96 71
Spina bifida 64 62
Encephalocele 37 34
Other brain
Microcephaly 126 127
Hydrocephaly 72 71
Holoprosencephaly 15 14
Eye and Ear
Microtia 39 39
Anotia 20 20
Microphthalmos 8 8
Anophthalmos 7 7
Orofacial
Cleft lip with or without cleft palate 203 204
Cleft palate without cleft lip 89 90
Heart
Tetralogy of Fallot 29 29
Coarctation of aorta 18 19
Transposition of great vessels 17 17
Hypoplastic left heart syndrome 15 15
Gastrointestinal
Anorectal atresia/stenosis 50 51
Esophageal atresia 17 17
Genitourinary
Hypospadias 40 41
Indeterminate sex 29 29
Cystic kidney 17 17
Renal agenesis 15 14
Undescended testis 8 8
Limb
Limb anomalies, total 81 81
Limb deficiency, transverse 29 29
Limb deficiency, axial 17 17
Polydactyly preaxial 13 14
Limb deficiency, unspec. 10 10
Limb deficiency, preaxial 8 8
Limb deficiency, postaxial 8 8
Limb deficiency, intercalary 7 7
Abdominal
Gastroschisis 89 88
Omphalocele 40 41
Diaphragmatic hernia 35 35
Prune belly sequence 5 5
Chromosomal
Down syndrome 327 309
Trisomy 18 101 41
Trisomy 13 35 24
Note: includes conditions with at least 5 estimated cases. Assumes that prevalence estimates from program are valid country-wide.

Outcomes - early mortality

The relative impact of congenital anomalies on early mortality (neonatal, infant, and under 5 years) tends to increase as infant mortality due to other causes falls. This pattern has been observed worldwide. These general indicators of early mortality are tracked regularly by public health agencies.

Mortality Indicators, Chile

Key Indicator 2022 data
Neonatal mortality (per 1000) 4.1
Infant mortality (per 1000) 5.4
Under 5 mortality (per 1000) 6.3
Source: World Bank, accessed Sept 2024

Outcomes - mortality with congenital anomalies

A more specific indicator (infant deaths due to congenital anomalies) is more challenging to document accurately. Missed diagnoses, especially of internal anomalies, can lead to massive underestimates, especially in settings where diagnoses rely only or mostly on an external exam. The table below summarizes data and estimates from systematic public sources. However, local assessments from birth defect surveillance program can help improve the quality of this key indicator.

Deaths due to birth defects, Chile

among infants (< 1 year old) and from first to fifth birthday
Age group Percent

Deaths
/ 100k pop

Infants 38.7
185.2
1 to < 5 yrs 17.9
4.1
Source: WHO mortality data 2021 | who.int

Risk factors

Some modifiable exposures are well-established risk factors for congenital anomalies. Reducing these exposures is the basis for effective primary prevention. Here we focus specifically on smoking, diabetes, and folate insufficiency. These factors, both common and modifiable, increase the risk of major contributors to morbidity and mortality, including orofacial clefts, neural tube defects, and serious congenital heart disease. The impact of these risk factors depend on their frequency in the population. The following tables show frequency estimates for the country. In another section, these data are used to estimate the number of cases in the country potentially preventable by eliminating the risk factors.

Smoking

Smoking is associated with increased risk for many adverse pregnancy outcomes and several congenital anomalies, including orofacial clefts and probably congenital heart disease. The increased risk is relatively modest (odds ratios tipically less than 1.5) but the effect size, or number of cases due to smoking, depends on the rate of smoking among women who become pregnant. Here we used country-specific estimates of smoking in women of reproductive age (see table for references). Rates of smoking during pregnancy tend to be lower, but by the time many women know they are pregnant, the at-risk period for congenital anomalies has often already passed.

Smoking in women

Frequency in two different groups, Chile
Women Frequency (%)
Of reproductive age 32.8 ( 27.4 - 38.3 )
During pregnancy 24.9 ( 22.3 - 27.6 )
Source: IHME | www.healthdata.org | and Lange 2018

Diabetes

Maternal pregestational diabetes is associated with increased risk for many serious congenital anomalies, including spina bifida, several critical congenital heart defects, and multiple congenital anomalies, among others. In some cases the relative risk (or odds ratio) can be quite high, above 4 or 5 in some cases. The effect size (number of cases due to diabetes) depends on the frequency of diabetes, which tipically increases with age.

Diabetes in women

Frequency by age group, Chile
Age Group Percent
15 to 19 0.2
20 to 24 0.5
25 to 29 0.9
30 to 34 1.4
35 to 39 2.1
40 to 44 3.0
45 to 49 4.2
Source: IHME | www.healthdata.org

Folate insufficiency

Folate insufficiency is associated with increased risk for neural tube defects and perhaps other congenital anomalies. On a population-basis, well-implemented folic acid fortification is estimated to decrease the prevalence of neural tube defects below 6 per 10,000 or perhaps even lower. Folic acid fortification is most effective when it is mandatory and universal, meaning that it involves foods commonly consumed by large parts of the population (e.g., wheat, maize, rice, depending on culture and geography).

Folic acid fortification

Status of mandatory fortification in Chile
Mandatory Food vehicle Year started
Yes Wheat flour 2014
Source: FFI | fortificationdata.org

What if - prevention scenarios

What follows is a tricky but important exercise. By combining information about risk factors and prevalence of congenital anomalies, one can attempt to estimate the number of cases attributable to risk factors. This is illustrated in the table below, which uses prevalence information from the program and risk factor information (e.g., diabetes frequency in women) from country data. These estimates also require knowing the relative risk of disease given the exposure. Here we use odds ratios derived from high quality studies and metanalyses. These data then are fed into the Levine estimator of attributable fraction to generate the scenarios that you see in the table. For neural tube defects, we used a different approach. We used 6 per 10,000 as the (conservative) estimate of the birth prevalence achievable by fully implemented folate fortification, and postulated that a prevalence in excess of this value consists of cases attributable to folate insufficiency (as relates to neural tube defect prevention).

Attributable cases for selected risk factors

yearly estimates in program and in country, and per million births
Chile RENACH, 2017-2017

Prevalence
per 10,000

attributable cases Risk factor parameters

Program

Country

per 1M births

Orofacial
Cleft lip with or without cleft palate 8.8 12 20 88 smoking, freq: 32.8%, OR: 1.34
Cleft palate without cleft lip 3.9 4 6 26 smoking, freq: 32.8%, OR: 1.22
Neural tube defects (NTD)
Neural tube defects, total 8.5 34 58 250 Presumed folate insufficiency, prevalence > 6
Heart
Tetralogy of Fallot 1.2 1 1 4 diabetes, freq: 0.9%, OR: 4.89
Transposition of great vessels 0.7 0 0 1 diabetes, freq: 0.9%, OR: 3.34
Hypoplastic left heart syndrome 0.7 0 0 2 diabetes, freq: 0.9%, OR: 4.58

Odds ratios from literature, exposure frequencies from country estimates (see methods for details).
Estimates for neural tube defects are provided only when reported prevalence is greater than 6 per 10,000. Note that for programs that do not include stillbirths or terminations of pregnancy, these may be underestimates.

Arguably, these estimates are simplistic. For one, they assume accurate inputs and lack of interactions between risk factors. For neural tube defects, for example, the assumption is that the reported prevalence is accurate (e.g., that it includes stillbirths and pregnancy terminations) and that the excess prevalence is entirely due to (or preventable by) the folate status of the population.

For smoking and diabetes, these estimates assume, for example, that the reported smoking rates in women reflect the smoking rates in the at-risk period, typically the periconceptional period. Smoking rates in pregnancy are typically lower than rates among women of childbearing age, but many women realize they are pregnant after the at-risk period for many congenital anomalies. One may argue that the true smoking rates in the at-risk period are somewhere between these two estimates .

Finally, the computation of attributable cases in these scenarios considers risk factors ‘one at the the time’ and does not account, for example, for multiple exposures (e.g., diabetes and smoking) or interactions among multiple exposures. And so on.

Nevertheless, even rough estimates provide an important message. Some instances, perhaps many, of major and even lethal congenital anomalies are preventable by reducing the burden of risk in populations and individuals. Moreover, for many risk factors (smoking and diabetes in particular), the benefits of exposure mitigation extend beyond the prevention of congenital anomalies to the prevention of many other health conditions, for the fetus as well as for parents.